Exercise versus surgical intervention for pain and disability in adults with lumbar spondylolisthesis

Spondylolisthesis (SPD) is a condition that directly affects the vertebraand is most commonly seen in the lumbar spine (Earl, 2002). It is amovement or translation of one vertebral body over the other. Slippagemay be forward, backward, or sideways, but usually an anterolisthesis (forward movement) is implied by this term (Haun and Kettner, 2005).The most common types of SPD found in the adult population areisthmic and degenerative (Earl, 2002). Even though there are importantdifferences in these two types of SPD, the treatment approachto this condition remains the same. The main managementapproaches for lumbar spondylolisthesis are conservative treatment,and surgery (Vibert et al., 2006). Both interventions havebeen proven to work independently but the question still remains as to which route is the most beneficial for a satisfactory clinicaloutcome both in the short and long-term.ObjectivesTo determine whether exercise or surgery is more effective for thetreatment of lumbar spondylolisthesis in adults.MethodsA systematic search was conducted in MEDLINE, CINAHL, AMED,EMBASE, SPORTDISCUS, and EBMR for articles published throughNovember 2015. PICO was used to design the selection criteria forrelevant studies. Quality assessment was evaluated using the'Physiotherapy Evidence Database' (PEDro). A narrative synthesiswas conducted in order to analyse the relationships within andbetween the studies. Mean numerical values were presented as amean difference (MD) and the findings were compared to determinepotential heterogeneity of treatment effect.Results and discussionThree RCT's fulfilled all the inclusion criteria. Only one study showedsubstantially better results in pain and disability for surgery over exercisein the medium and long term (Moller and Hedlund, 2000).However, the evidence relating to efficacy is of low-moderate quality.Two studies reported that the benefits of surgery are likely to outweighthe possible harms (Moller and Hedlund, 2000; Weinsteinet al., 2007). Sample size, differences in inclusion criteria, age groups,cultural backgrounds, types of exercise, surgery approaches, and outcomemeasures makes the effects of the studies included in this reviewdifficult to assess for generalisability and applicability. Conclusion and significanceFollowing a rigorous search strategy, 3 studies were identified andincluded in the final review. Internal and external validity wasassessed and found to be low to moderate. The results found nosignificant differences between the two treatment strategies. OnlyMoller and Hedlund (2000) found posterolateral fusion to be moreeffective than exercise in the long term. Yet, methodological qualityof this paper was low-moderate, thus the results should be usedwith caution. No clear conclusions were drawn for the best treatmentstrategy. Further research is very likely to influence the estimatedeffect of the studies.